chiropractic intake form

8/14/2019 Chiropractic Intake Form

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Today’s Date: ______/______/_____

Patient Information:(Please fill this form out to the best of your ability.)

Patient Name (Last, First, M.I.): _________________________________________________ Nick Name: ______________

Address: _________________________________________ City: _________________ State: _______ Zip Code: _________

Home Phone: _____________________ Cell/Alternate Phone: ______________________ E-Mail:___________________

Employer: _________________________ Work Phone: ______________________ Can We Contact You Here? Yes

Social Security #: ________-______-________ Birth Date: _____/_____/________ Age: ______ Sex: Male Fem

Name of Spouse/Partner or Guardian (if underage):___________________________________ Birth Date: _____/_____/____

Emergency Contact: ______________________________ Relationship: ______________ Phone #:____________________

Names and Ages o f Children: ____________________________________________________________________________

Chose This Clinic Because…____________________________________________________________________________

Insurance Information:Are You Covered By Health Insurance? Yes No

Name Of Primary Insurance: __________________ Group/Account #:___________________ Policy #:__________________

Policy Holder’s Name: _________________________ Birth Date: _____/_____/______ Social Security #: ______-_____-___

Patient’s Relationship to Policy Holder: Self Spouse Child Other_________________

*Name Of Secondary Insurance: __________________________ (*If Applicable)

Group/Account #:_________________________ Policy #:_________________________

Policy Holder’s Name: _________________________ Birth Date: _____/_____/______ Social Security #: ______-_____-____

Patient’s Relationship to Policy Holder: Self Spouse Child Other_________________

Billing Information:

Person Responsible For Bill: ________________________ Birth Date: _____/_____/_____ Social Security #:_____-_____-__

Address (If Different):_______________________________ City: _________________ State: ________ Zip Code: ________

Home Phone #: ______________________ Is This Person Here? Yes No Relationship: _____________________

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physiciI understand that I am financially responsible for any balance. I also authorize the above listed clinic

or insurance company to release any information required to process my claims.

Signature (Guardian if underage):_________________________________________________ Date: ___________________



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Office Policies Regarding: Personal Health Insurance & Private Payment

1) We are providers for several insurance programs and managed care organizations. For your convenience we will verify your insurance benefits and submit claims as a courtesy to you. Howev

your insurance is a contract between you and your insurance company, NOT between Total HealthChiropractic and your insurance company. You are fully responsible for all charges due to servicesrendered. If payment is denied for any reason by your insurance company, you are then responsibfor full payment of those services rendered.

2) All charges must be paid at the time of services. This includes co-pays and deductibles.

3) Any insurance payments that have been paid directly to you by your insurance company must bereceived by Total Health Chiropractic no later than one week from receipt and endorsed to this clin

4) Please make payments on time. If you experience financial difficulties, please call us. We will do o

best to work out a payment plan. If balances are not paid within 90 days from the time of firststatement, and arrangements for payment have not been made, your account will be referred for leaction.

I have read, understand, and accept the insurance/payment policy at Total Health Chiropractic.

Patient Signature: ______________________________________ Date: _____________

HIPPA/Privacy Policies

Please see the form attached to the clipboard given to you. You may have a copy for your records simply asking the front desk. Thank you.

I have received, read, and understand the privacy policies of Total Health Chiropractic.

Patient Signature: _______________________________________ Date: ____________

Medical Record Release

I authorize Total Health Chiropractic to release any information in the event my insurancecompany/attorney requests records or information related to my treatment at your office.




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Chiropractic Informed Consent

Any procedure intended to help, may also do harm. While chiropractic and therapeutic procedures (e.gspinal adjustment, ultrasound, heat and cold, etc.) are considered remarkably safe and effective, pleasunderstand that occasionally there may be adverse reactions.

Although the chances of experiencing any of these complications are extremely small, it is the practicethis office to fully inform and educate all our patients. These complications include, but are not limited

Pain Swelling Inflammation Disc InjuryBurns Nausea Dizziness Worsening of conditionBleeding Sensory Changes Bone Fracture Soft Tissue InjuryBruising Stroke Weakness

I have read and understand the informed consent form of Total Health Chiropractic.


Consent to Treat a Minor

I, ___________________________________ (parent/guardian) give my permission to the provide

at Total Health Chiropractic to give spinal adjustment/manipulations and necessary therapies to

___________________________________ (child’s name).

Parent/Guardian Signature: ____________________________________ Date: ___________



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Patient Health Questionnaire

1. Symptoms began on: _____________ Height: ______ Weight: ______

2. Briefly describe your symptoms: ________________________________

__________________________________________________________

__________________________________________________________

3. How did your symptoms start? _________________________________

__________________________________________________________

4. Average pain intensity:

a. Last 24 hours: (no pain) 1 2 3 4 5 6 7 8 9 10 (worst pain)

b. Past week: (no pain) 1 2 3 4 5 6 7 8 9 10 (worst pain)

5. How often do you experience your symptoms?

1 – Constantly (76-100% of the time) 2 – Frequently (51-75% of the time) 3 – Occasionally (26-50% of the time) 4 – Intermittently (0-25% of the time)

6. How much have your symptoms interfered with your daily activities? (Including both work outside the home and housewo

1 – Not at all 2 – A little bit 3 – Moderately 4 – Quite a bit 5 – Extremely

7. How are your symptoms changing?

1 – Getting Better 2 – Not Changing 3 – Getting Worse

8. Have you seen anyone else for your symptoms? 1 –Yes 2 – No

If “yes”, who and what treatment? _____________________________________________________

9. In general, how is your overall health right now?

1 – Excellent 2 – Very Good 3 – Good 4 – Fair 5 – Poor

10. Past/Present Health History (Please indicate any other health conditions past or present in the area below)

Headaches Stroke Asthma

Back Pain Heart Attack Shortness of Breath

Neck Pain Heart Disease Depression

Joint Pain High Blood Pressure General Fatigue

Arthritis Sinus Problems/Allergies Abnormal Weight Loss/Gain

Kidney Disorders Dizziness Cancer/Tumor

Change in Bowel Function Diabetes Smoking/Tobacco Use

Change in Bladder Function Excessive Thirst Drug/Alcohol Dependence

Digestion Problems

Frequent Urination

Birth Control Pills (Female Only)

Stomach Pain Prostate Problems Pregnancy (Female Only)

11. List all prescription and over-the-counter medications, and nutritional/herbal supplements you are taking:

____________________________________________________________________________________

12. List all surgical procedures and hospitalizations:

____________________________________________________________________________________

Patient Signature: _____________________________________________ Date: ____________________

Please indicate areas of pain or other sym

chiropractic intake form

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